Chapter 12 Upper limb trauma I
Structured oral examination question 1#
Fracture dislocation shoulder
A 38-year-old left-hand dominant lady fellon to her right arm when outdrinking and attended the accident and emergency department the next day at 4 pm as the pain in the right shoulder had not setiled down. These are the X-rays of her right shoulder (Figure 12.1a). What is your diagnosis?
Anterior dislocation of the right shoulder with an associated greater tuberosity (GT) fracture. Complete loss of joint congruence is demonstrated on the AP view, while the anterior displacement is best demonstrated on the axial view. There is no visible evidence of fracture through the anatomical neck, although this occurs in about 10% of cases. This pattern of injury is more in keeping with this patient age than surgical neck fracture, which is more typically seen in an older demographic.1
How will you manage this condition?
Assess the patient according to ATLS protocol and exclude any neurovascular injury because brachial plexus injury is part of a recognized pattern comprising the ‘terrible triad’ of the shoulder.2 If there was suspicion of an undisplaced neck fracture, I would obtain an emergency CT to confirmand then plan for open reduction and fixation of both the neck and G T fractures. I would perform a neurovascular examination of the shoulder and document my findings in the case notes before attempting manipulation. I would reduce the shoulder dislocation under sedation using the scapular manipulation technique, as this is the most successful and least painful method with no reported incidences of fracture. This involves the patient lying prone with a weight applied to the arm while the tip of the scapula is rotated medially and upward. I would immobilize the limb in a shoulder immobilizer. After manipulation I would obtain anteroposterior and axial radiographs and repeat a neurovascular examination of the involved limb.
What are the risks and complications you anticipate?
During reduction the reis a risk of displacing an unseen humeral neck fracture or propagating the G T fracture through the neck. Other risks are injury to axillary nerve and artery, brachial plexus and rotator cuff injury.3
Attempted closed reduction in the accident and emergency department has failed and it is 7 pm now. What will you do next?
I will take into account availability of space on the emergency list, presence of neurological symptoms, the patient level of pain and level of anaesthetic risk. If it is safe and within a reasonable time fr ame, I would take the patient for closed reduction undergeneral anaesthetic. After reduction I would reassess the neurovascular status. If there was a new neurovascular deficit, this may be due to nerve entrapment. In this situation, I would plan for a shoulder surgeon to explore the nerve and perform an open reduction in the morning. If there was going to be a delay in taking the patient to theatre for reduction, as longas there was no neurovascular compromise I would plan for emergent reduction and/ or fixation by a shoulder surgeon on the next available list.
What manoeuvre would you perform to achieve shoulder reduction?
Under complete muscle relaxation, I will use the traction/ countertraction method given that scapular manipulation has failed. This is the second most effective technique and the associated discomfort will not be felt by the anaesthetized patien t.4 Because failure of reduction may be due to head impaction on the anterior glenoid, this technique also allows controlled external rotation to disengage this.
What other factors may prevent a closed stable reduction of the dislocation?
A large rotator cuff tear or axillary nerve injury may prevent the shoulder from remaining in joint. On occasion, the longhead of the biceps may get caught up posterior to the humeral head and prevent reduction. The stability of the joint may also be affected by a structural deficit such as a bony or soft -tissue Bank art lesion or a Hill–Sachs lesion.
Next day in theatre, closed reduction is achieved (Figure 12.1b). What will you do next?
I will assess the greater tuberosity fracture reduction. If it isless than 5 mm superiorly displaced, I will treat it non-operativ ely with a polysling for 3 weeks with serial X-rays on a weekly basis and if there is no fracture displacement, I will start shoulder mobilization under physiotherapy care.5
X-ray of right shoulder one week later is shown in Figure 12.1c. What will you do?
I will arrange a CT scan of the shoulder to assess the degree and direction of displacement as this is useful in borderline cases.6
The CT scan (Figure 12.1d) of the right shoulder shows no humeral neck fracture but significant displacement of the greater tuberosity. What will be your management strategy?
If the greater tuberosity fragment has posterosuperior displacement more than 5 mm,7 I would offer the patient reduction and fixation. Arthr oscopic fixation with a doubler ow of anchors may be possible – it isless invasive than ORIF and has demonstrated superior postoperative range of motion. 8
What are the risks of non-operativ e management of displaced greater tuberosity fracture?
Non-union, malunion, which effectively narrows the subacromial space, leading to mechanical impingement and consequent rotator cuff atrophy.9
Figure 12.1a Anteroposterior (AP) radiograph of right shoulder demonstrating fr acture/dislocation.
Figure 12.1b II films, relocated right shoulder.
Figure 12.1c Anteroposterior (AP) radiograph, right shoulder with greater tuberosity fracture.
Figure 12.1d CT image, right shoulder.
Structured oral examination question 2#
Right wrist fracture
A 24-year-old man fell down the last few steps of a flight of stairs and sustained an injury to his right wrist. His X-rays are shown in Figure 12.2a. What is this injury?
There is a displaced radial styloid fracture, which is classically termed a ‘chauffeur’s fracture’.39 In addition, the reis radiocarpal dislocation. This is demonstrated by more than 50% of the lunate having subluxed ulnarly from its fossa. This pattern would be classified by AO as type B2.3 and its pathomechanism is suggested to be an avulsion of the styloid by the radioscaphocapitate ligament.10 On these images there is no visible scaphoid fracture or evidence of scapholunate ligament disruption however, this would be a common association.
What other injuries have occurred in addition to the radial styloid fracture?
Rupture of volar capsule and radiolunate ligaments, while the radial collateral and volar radiocarpal ligaments are attached to the fragment, allows subluxation of the radiocarpal joint.11 The distal part of the brachioradialis insertion is typically 17 mm from the tip therefore, with this relatively distal fracture, there is no stabilizing force from the brachioradialis.12
How will you manage this injury?
Assuming it is an isolated closed injury, I will attempt closed reduction under sedation in casualty, apply a below-elbow moulded dorsal plaster slab, check the distal neurovascular status and get a repeat X-ray of the wrist. Given that this is a type B injury with a high-energy mechanism, I would also arrange a CT to assess for any associated carpal fracture as well as articular reduction. 13
Figure 12.2b shows a postreduction X -ray. How will you manage this injury?
Postreduction X -rays show that the fracture is well reduced, and the radiocarpal alignment is satisfactory. Given that the CT demonstrated < 2 mm articular disruption, no carpal fracture and radiocarpal congruency, I would treat this in a moulded plaster and weekly radiographic follow-up. If there was evidence of instability, I would offer ORIF of the radial styloid alone, as this should restore radiocarpal stability.14 If there was evidence of further instability, repair of volar radiocarpal ligaments may be necessary. Neurovascular decompression, joint debridement and management of inter- and transcarpal injuries may also be addressed.
Figure 12.2a Anteroposterior (AP) and lateral radiographs, right wrist.
Figure 12.2b Anteroposterior (AP) and lateral postreduction film, right wrist.
Structured oral examination question 3#
Comminuted elbow fracture
A motorbike rider came off his bike at around 80 miles/hour and has sustained an isolated injury to his right elbow. X-rays in casualty are shown in Figure 12.3a.
This X-ray of the right elbow demonstrates a bicolumnar distal humerus fracture. It is intra- articular , complete articular and the reis comminution of the articular surface. There is evidence of a well-healed distal humerus diaphyseal fracture which was stabilized with an intramedullary nail. The dressings around the elbow suggesta possible open injury. I will assess the patient according to ATLS protocols and assess neurovascular status. I will also check if it is an open fracture.
How are these injuries classified?
Intra-articular fractures can be divided into partial or complete according to the AO classification. In type B fractures, a single column is involved while the articular surface of the other column remains incontinuity with the diaphysis – this is ‘partial articular ’. In type C fractures, both columns are involved and there is no continuity between any part of the articular surface and the diaphysis – this is ‘complete articular ’. The severity of these fractures depends on whether their articular and metaphyseal components are simple or multi fragmentary.
This is an open fracture. How will you deal with the wound in casualty?
According to BOAST 4 and NICE guidance 37, in conjunction with Orthoplastics input, I will remove gross contamination but not irrigate the wound. I will document and photograph the wound for size and tissue loss then dr ess with saline-soaked gauze and an occlusive dressing and splint the limbI will check the patient tetanus status and give a booster dose if required and analgesia. I will start the patient on intravenous co-amoxiclav which will continue un til 72 hours after initial debridement or wound closure.
What will be the definitive management and its timing?
This will depend upon vascular status and orthoplastics input. If the reis vascular compromise, this would necessitate immediate appropriate surgery. If there is evidence of compartment syndrome, this would warrant immediate fasciotomy. Otherwise, the patient should betaken to theatre by a senior plastic and orthopaedic surgeon on a scheduled trauma list within 24 hours but ideally within 12 hours for high-energy injuries such as this. Initial debridement consists of excising wound edges and extending the wounds in conjunction with plastics to ensure that this will not compromise their plans for soft -tissue coverage. I will deliver the bone ends and excise devitalized bone and ensure the medullary cavity is clean, which in this case may necessitate removal of the humeral nail. I would then irrigate the wound with 6 litres of gravity-assisted normal saline. If the patient is systemically stable and immediate soft -tissue coverage was possible then I would progress to definitive internal fixation or hemiarthr oplasty. Otherwise I would perform limited fixation of the articular fragments , apply a negativ e-pressure dressing and span the zone of injury with an external fixator.
If the wound is satisfactory and definitive stabilization is planned, how will you go about it?
In an appropriately marked, consented and anaesthetized patient, I would position in a lateral decubitus position. My approach would be posterior under guidance of plastics likely incorporating the existing defect. An olecranon osteotomy would aid visualization of this in tra- articular fracture. If the nail is still in situ, I would plan my fixation around this, although as the old fracture is well healed, removing the nail is an option if this would make fixation or arthroplasty of the new fracture easier. Principles of fixation are anatomical reduction and rigid fixation of the articular fragments and functional alignment and relative stability of the metaphyseal and diaphyseal sections According to the principles setout by O’Driscoll,15 I would initially reduce the articular fragments and stabilize with K-wires. I would use one pre-contoured locking plate on each column. Ensure that every screw went through the plate. Every screw is anchored in a fragment on the other side. As many screws as possible are placed in the distal fragments. Screws should beas longas possible. Distal screws should engage as many fragments as possible. Distal screws should interdigitate. Plates should apply compression at the supracondylar level. Plates should be strong enough to resist breakage. If there was bone loss, I would shorten the humerus to achieve good bony contact.
How will you stabilize the olecranon osteotomy?
With a traditional apex distal chevron osteotomy, I will use a 6.5-mm partially threaded screw with a washer in a pre-drilled hole as this has been demonstrated to give the highest rate of union and lowest rate of implant removal.16 However, there is increasing evidence that an extra- articulars tep-cut osteotomy may produce a more stable construct with a much higher bone contact surface area.17
This is the postoperative X-ray (Figure 12.3b). What will be your postoperative management?
There is stable anatomical fixation of the distal humerus. The olecranon osteotomy has been fixed with a partially threaded screw; however, there is a gap at the osteotomy site. I would allow active assisted mobilization of the elbow and monitor for displacement of the osteotomy. If there were signs of radiological displacement or clinical non-union, I would revise the fixation using a screw with a washer.
I would consider the use of prophylaxis for heterotopic ossification.
Why not plate the osteotomy?
That would be my plan B if the screw and washer failed to achieve compression. I would initially try to avoid plate fixation ast here is already a significant amount of metalwork around the elbow.
Figure 12.3a Anteroposterior (AP) and lateral radiographs, right elbow, demonstrating comminuted fracture.
Figure 12.3b Anteroposterior (AP) and lateral radiographs, right elbow, postfixation.
Structured oral examination question 4#
Monteggia fracture
A cyclist was knocked over by a car and he landed on his elbow. This is an isolated injury. His X-rays are shown in Figure 12.4a.
This is a Monteggia fracture–dislocation. The ulna has a comminuted metaphyseal fracture with apex posterior and the radial head is dislocated posteriorly as is seen most commonly in adult injuries. This would be classified by Ba doas a Type 2 with disruption a t the proximal radioulnar joint. The fracture may extend across the base of the coronoid, although this is undisplaced and the greater sigmoid notch appears to be preserved. A radial head fracture is associated with this pattern of injury and should be carefully examined for. As with all high-energy injuries I would assess the neurovascular status for wounds indicating an open injury.
How will you manage this?
I will reduce the fracture in A&E, apply an above-elbow backslab then reassess the neurovascular status and check position with a plain radiograph. I will then offer the patient open reduction and internal fixation.
Can this fracture be treated non-operativ ely?
Unless there was an absolute contraindication such as the patient being unfit for surgery or refusing surgery, I would treat this operatively. The fracture is comminuted and is therefore unstable and will allow further dislocation of the joint with limitation of range of motion. There may be loose fragments within the joint which will cause locking. The lateral ulnar collateral ligament is commonly injured with this pattern and may result in instability even if bony alignment is restored. Fixation allows early mobilization and reduced stiffness. In an appropriately marked and consented patient, I would position the patient lateral decubitus with the arm over a support. I would use the posterior approach and assess for displacement of a coronoid fragment. If this was present I would reduce and stabilize this through a split in the flexor- pronator mass. I would use a pre-contoured locking plate to bridge the comminuted region and restore length and alignment. Stabilization of the coronoid fragment may be achieved via a screw through the plate. I would then assess the range of motion and stability. If the radial head is fractured I would consider fixation or metallic replacement.
What are the causes for the radial head continuing to sublux after ulna fracture stabilization?
Malreduction of ulna fracture – either malalignment or shortening. Capsuloligamentous, coronoid or radial head deficiency. For posterolateral instability, injury to the lateral ulnar collateral ligament is most likely to play a role. Annular ligament interposition is uncommon. If the elbow remained unstable after addressing all of the above, then I would use a temporary static external fixator.
This is the postoperative X-ray (Figure 12.4b). What will be your postoperative management?
I will protect wound healing with a back-slab for 2 weeks then start physiotherapy with active movement as tolerated to prevent stiffness and f ollow-up the patient to make sure the wound and fracture have healed along with good functional out come. I would consider the use of prophylaxis for heterotopic ossification as this is common after elbow trauma. I would also monitor for joint subluxation, loss of fixation, non-union and progressive arthrosis.
Figure 12.4a Anteroposterior (AP) and lateral radiographs, Monteggia fracture–dislocation, right elbow.
Figure 12.4b Anteroposterior (AP) and lateral radiographs, right elbow, postfixation.
General reading#
Wong JC, Getz CL, Abboud JA. Adult Monteggia and olecranon fracture dislocations of the elbow Hand
Clin. 2015;31(4):565–580.
Structured oral examination question 5#
Galeazzi fracture
A 23-year-old male while on a night out fellon to his left hand and has come to casualty with pain and deformity. The X-ray of his left distal forearm is shown in Figure 12.5.
This is a Galeazzi fracture. There is a diaphyseal fracture of the radial shaft associated with dislocation of the distal radioulnar joint. There is significant shortening of the radius, widening of the DRUJ on the AP view. I will assess the patient with regards to medical conditions, associated injuries, distal neurovascular status and whether it is a closed or open injury.
This is an isolated closed injury with no distal problems. How will you manage this injury?
I will try to reduce the fracture dislocation in casualty under sedation, apply an abo ve-elbow back-slab with the forearm in supination and get an X-ray of the forearm and wrist. Having said that, these are often quite difficult to reduce closed and reduction may not be possible.
Check X-ray shows no change in position, it is 9 pm. What will you do?
If there are no signs of any neurovascular deficit, I will prioritize the patient in the next day’s trauma list for open reduction and stabilization of radial fracture with stabilization of the distal radioulnar joint, if required. Overnight, the arm will be kept elevated and frequent neurovascular assessment will be made.
How will you fix this fracture?
I would use a dynamic compression plate of the radius through a volar Henry’s approach, aiming for absolute stability. Bone healing will be primary. There is no need to use a locking plate in this situation as he is a young patient with good bone quality.
What are the prerequisites for primary osteonal fracture healing?
Absolute stability at the fracture site with a strain environment less than 2%, perfect reduction with the bone ends touching so that the cuting c ones can pass across the fracture site and viable bone end.
During surgery the radius fracture is stabilized, but the distal radioulnar joint is still dislocated. What are the causes for this?
The radius fracture may have been fixed in either a shortened or angulated position. There may be soft -tissue interposition (most commonly the ECU tendon) or a bony fragment in the distal radioulnar joint. There may be disruption of the TF CC allowing redislocation of the DRU J.
Radius fracture reduction is satisfactory and there is no interposition, but the joint is dislocated. How will you deal with it?
This implies that the TFCC is defunctioned. This may be due to an ulnar styloid fracture – if so, I would open this, reduce it and fix using a tension band technique. Otherwise, I would explore the DRUJ via a dorsal approach and repair the TFCC and other soft -tissue restraints. Following stabilization, I would protect the repair using two K-wires just above the sigmoid notch with the forearm in neutral.
What will be your postoperative protocol?
If the DRUJ was stable I would mobilize this patient early after a couple of weeks of immobilization however, as the TFCC has had to be repaired, I will keep the arm immobilized for longer. He will need the arm in an above-elbow plaster (to immobilize the DRUJ) for around 4 weeks, at which point the K-wires can be removed and he can be put into a splint. A sugar tong splint would protect the DRUJ while allowing some elbow movement.
Figure 12.5 Anteroposterior (AP) and lateral radiographs, left forearm.
Topic reference#
Giannoulis FS, Sotereanos DG. Galeazzi fractures and dislocations . Hand Clin. 2007;23(2):153–163.
Structured oral examination question 6#
Humeral shaft fracture
A 58-year-old man sustained an injury to his arm when he fell from standing height. He is right-handed, suffers from hypertension and has a sedentary lifestyle. His X-rays are shown in Figure 12.6a.
The X-rays show a simple transverse fracture of the right humeral shaft in the middle third, distal to the deltoid tubercle. There is 100% translation however, the bone ends are in contact, there is no evidence of shortening and there isless than 20° of angulation in either view. I will check for other injuries, neurovascular status and whether it is a closed or open fracture.
It is a closed fracture with no associated problems. How will you manage it?
In casualty, I will apply a U-slab, then check for distal neurovascular status and get a check X- ray. The majority of patients can be successfully managed with a functional br ace applied after the swelling starts to setile and gentle mobilization. Internal fixation would allow earlier mobilization and is one of the indications for surgery.
What will you do once the humeral brace is applied?
I will encourage pendulum exercises and active hand and wrist movements. I will get a check X-ray to ensure the fracture has not displaced, then I will monitor the position with weekly serial radiographs for 3 weeks. I will advise the patient to adjust the tension of the brace twice-weekly.
At 2 weeks the repeat radiograph (Figure 12.6b) shows some distraction a t the fracture site, what will you do?
This may imply interposed tissue with a potential for non-union. I will explain that the rate of non-union may be as high as 20% with non-operativ e and 10% with fixation. The fracture is transverse, the contact area is small; therefore, this fracture may be at a higher risk of non-union. I would mention that we can continue with conservative treatment, but also give the patient the option of sur gery.18
The patient does not want to wait and see. He is in a lot of pain and is struggling with the humeral brace. He is keen for fixation. What will you do?
I will discuss with the patient the advantages and risks involved inoperative fixation of humeral fractures. The rate of non-union may be reduced, the rate of malunion is certainly reduced and the rate of nerve injury does not appear to be increased in using plate fixation. There are, however, risks of iatrogenic radial nerve injury, infection stiffness, implant failure and CRPS.
What operative intervention will you undertake?
Plate or nail fixation is possible, but I would offer plate fixation using a large fragment DC Pas this has been demonstrated to have a lower risk of shoulder impingement than intramedullary nailing.
This is the X-ray at 3 months (Figure 12.6c). What will you do?
My first aim will be to rule out infection. I will check the patient for systemic illnesses, like fever, chills, shivering, loss of appetit e/weight. I will also perform bloodtests – FBC, CRP.
The patient has no symptoms and is happy with progress with physiotherapy. Why do you suspect infection?
In a plate fixation, absolute stability is the aim. This means that the fracture will heal by primary intention. In the presence of callus formation, I will suspect infection ora septic implant loosening. This last question is about primary healing in rigid/stiff fixation. When the reis callus formation in these ‘rigid fixations ’, especially of transverse or oblique fractures, then the possibility of either early plate loosening of grumbling infection should be kept in mind. Although external callus can occur in plate fixations, in these circumstances the stiffness of the construct is lower and is flexible enough to allow secondary fracture healing as the working length is longer. A perfectly plated Swiss fracture does not go through endochondral repair.
Figure 12.6a Anteroposterior (AP) and lateral radiographs, transverse fractured left humerus.
Figure 12.6b Anteroposterior (AP) radiograph, distracted left humerus fracture.
Figure 12.6c Anteroposterior (AP) radiograph, non-union left humerus fracture post-plate fixation.
Structured oral examination question 7#
Clavicle fracture
A 70-year-old female falls awkwardly on to her left side and presents with pain and bruising to her shoulder.
This is an AP radiograph of the left clavicle – it demonstrates a mid-shaft clavicle fracture (Figure 12.7). There is evidence of a buft erfly fragment, and there is overlap of the bone ends indicating shortening. I would assess for any neurovascular deficit and assess the skin for any skin tenting.
How would you manage this patient?
I would discuss the pros and cons of conservative vs. surgical management. The potential advantages of surgery being lower rate of non-union, earlier mobilization, pain control and better outcome scores at one year.19
What factors are predictive of a poor outcome with conservative management?
Smoking is the most strongly associated factor along with comminution and displacement. Robinson has demonstrated that the risk of non-union can be predicted according to independent risk factors of comminution and displacement in an older female.20 More recently, elevated PROMs at 6 weeks have also been demonstrated to be predictive of non-union.21 This information is invaluable in helping patients to decide whether to opt for surgery. By selecting out those a t a particularly high risk, the number needed to treat to prevent non-union can be reduced – in preventing non-union, an improvement in DASH scores can beseen. Shortening has previously been suggested as an indicator for surgery, and although recent evidence argues against this in the short term,22 it may have a functional effect in the longer term.
How would you fix this fracture?
I would use plate fixation as this has been demonstrated to have a lower rate of non-union than intramedullary fixation in comminuted fractures.23 In an appropriately marked and consented patient, I would position them in a beach chair position with the arm prepped . I would use a ‘necklace’ incision as this provides a more satisfactory scar. I would use an anteroinferior plate in the middle third of the clavicle as there is evidence that this produces a quicker operation, less blood loss and the plate is significantly better tolerated. I would use a superior plate if involving the medial third due to close proximity of the subclavian vessels posteriorly in this region.
Figure 12.7 Anteroposterior (AP) radiograph, mid-shaft fractured left clavicle.
Structured oral examination question 8#
ACJ dislocation
A 25-year-old rugby player landed heavily onto the tip of his shoulder and is now complaining of pain on moving his shoulder – what can you see (Figure 12.8)?
This is an AP radiograph of the shoulder demonstrating superior subluxation of the lateral end of the clavicle relative to the acromion. There is complete loss of articulation between them – i.e. the acromioclavicular joint (ACJ) is dislocated. I would classify this as type 3 according to Rockwood, although the interobserver reliability of this system is limited.24 Therefore, it is important to assess stability clinically – the cross-arm adduction (sc arf) test may demonstrate painful posterior instability and this is an indication for surgery.
What is the sequence of pathoanatomy in ACJ injuries?
Initially the reis a sprain of the AC ligaments. Next the AC ligaments rupture and there is a sprain of the coracoclavicular (CC) ligaments allowing subluxation of the joint. If the CC ligaments rupture, this will allow complete dislocation The clavicle can then displace posteriorly through the trapezius muscle or superiorly if the deltoid and trapezius become completely detached. Rarely, the clavicle can also displace inferiorly.
How would you manage this patient?
As previously mentioned, it is important to assess stability. In a stable injury I would manage this patient conservatively with a sling for 2 weeks followed by mobilization. The natural history for type 3 injuries has demonstrated that although there may be a permanent cosmetics tep-off (although this needs to be balanced with a surgical scar), the functional deficit is minimal and well tolerated in the majority of patien ts.25 Recent systematic reviews and multic entre randomized controlled trials have demonstrated no difference in outcomes between conservative and operative management;26 however, the most common operative intervention in these studies is clavicular hook plate fixation.
What are the other surgical options and how do their outcomes compare?
The modified Weaver–Dunn technique has largely been superseded by anatomical reconstruction techniques, of which multiple studies have demonstrated superior PROMs data and a lower loss of reduction. 27 I would use a loop suspensory fixation technique as this is straighfoorward and allows early mobilization when compared to hook plate techniques.
What are the indications for operative intervention?
There are few absolute indications for surgery such as skin-tenting or an open injury. Otherwise, the consensus is that types 4, 5 and 6 should be managed operatively in order to reduce the ACJ where the clavicle may have buft on-holed through fascia or lie subcutaneously.28 The art of managing these injuries is differentiating between type 3 and type 5 injuries, which may have very similar radiographs. Although the general belief is that patients participating in overhead sports or occupations benefit from operative intervention, the reis litile clear published data.
Have you heard about LARS reconstruction?
LARS is a synthetic ligament augmentation and reconstruction device. It acts as a reinforcement to allow the coracoclavicular ligament to heal and grow into the synthetic device. The fixation is via two tunnels and not an over-the-top approach, thus reducing clavicular erosions. Two tunnels are drilled in the clavicle either side of the coracoid process. A LARS ligament is passed under the coracoid and through the tunnels in the clavicle. The clavicle is then aligned with the acromion and titanium screws are placed in the tunnels. The ends of the ligament are trimmed flush to the clavicle in order to avoid any irritating projections.
Figure 12.8 ACJ dislocation. The reis marked widening of the ACJ space with the distal clavicle positioned superior to the superior border of the acromion and a marked increase in the coracoclavicular distance.
Structured oral examination question 9#
Proximal humerus fracture
This 65-year-old lady has fallen onto her right side and sustained the following injury (Figure 12.9).
This is an AP radiograph of the left shoulder demonstrating a tw o-part, varus displaced, surgical neck of humerus fracture. I would take a history and examine the patient looking for evidence of neurovascular deficit – particularly in the axillary nerve. I would rule out other injuries and look for any signs in the history that this could be pathological, although this is not evident on this radiograph. This fracture could be classified according to Neer, although the reliability and clinical relevance of this system has been demonstrated to be limited. More recently, a pathomorphologic system assessing qualitative elements has been demonstrated to have a stronger reliability and good correlation with indication for surgery.29 I would consider a CT if the pattern was unclear.
What other factors affect the prognosis of these fractures?
Hertel has demonstrated a strong association between several radiological factors and avascular necrosis. These are a medial metaphyseal extensionless than 8 mm, medial hinge displacement more than 2 mm and fracture patterns involving the anatomic neck.
What is the blood supply of the humeral head?
The classical understanding of the vascularity was that the anterior circumflex artery was the dominant supply via the arcuate artery. However, a recent MRI study has suggested that the posterior circumflex artery is dominant.30
How will you manage this patient?
I would discuss the options with regards to the fracture pattern, the patient’s comorbidities and functional expectations. Although the recent PROFHER trial has suggested that surgical fixation is no better than conservative management in managing these fractures, there are significant limitations in these c onclusions.31 The first is that many patients who were felt to have a ‘clear indication for surgery’ were excluded, producing a subjective selection bias. The number of cases per surgeon was quite low and the subspecialization of the surgeons is unknown, leading to suggestions that management by a shoulder specialist may provide better results with surgery. In addition, the fracture patterns were categorized according to Neer rather than pathomorphology, and therefore it is difficult to differentiate whether there is a subgroup which would benefit from surgery. It is accepted that fracture morphology influences the decision whether to operate.32 Given that a residual varus deformity is associated with poor functional out comes,33 I would give this patient the option of ORIF .
What if you take this patient for ORIF and find that it is difficult to reconstruct?
There are a number of techniques to manage this fracture – conservative fixation, hemiarthroplasty and reverse-polarity arthroplasty. In a fit and active 65-year-old patient, I would persist with fixation given that arthroplasty doesn’t have fantastic outcomes, and, in this age group, is likely to require revision; there is also evidence that reverse arthroplasty after failed ORIF still has reliable outcomes.34 If it was decided that a similar fracture was notre constructable then arthroplasty should be considered. Although this is a contentious issue, with ongoing multic entre randomized trials like SHERPA, a recent meta-analysis suggests a reverse may be superior to a hemiarthroplasty.35
Figure 12.9 Anteroposterior (AP) radiograph of varus proximal humerus fracture.
Structured oral examination question 10#
A man presents to your fracture clinic complaining of pain in the antecubital fossa of the elbow and weakness of his biceps 4 weeks after injuring it at the gym. What is the likely diagnosis and how would you assess the patient?
This is a likely distal biceps tendon rupture. I would assess for localized bruising and tenderness and if there is a palpable gap in the biceps tendon. In addition, I would assess the neurovascular status of the arm and perform a hook testI would take a history looking for risk factors such as anabolic steroid use and smoking.
Why might the hook test be difficult to interpret, and the muscle belly retraction be minimal?
The distal biceps has distinct insertions of the long and shortheads a t the radial tuberosity; therefore, there may be an incomplete rupture. In addition, the lacertus fibro sus may tether the tendon. In this situation, I would request an MR Ito clarify the diagnosis and assess for tendon retraction.
The MRI demonstrates a partial t ear.
I would review the patient functional demands and expectations. Non-oper at ive management is an option in this situation; however, in the active patient pain symptoms may be persistent. If there is failure of conservative management, I would proceed to surgical treatment – completing the t ear and anatomically repairing it. There is a high rate of satisfaction reported for this approach.36
How would you approach this?
I would use a single-incision technique to relocate and fix the distal biceps tendon to the radial tuberosity. A number of fixation techniques are described, although acor tical buft on has demonstrated lower complication rate than suture anchors or transosseous screws.37 In this case, I would use a transverse incision over the elbow, with the potential to extend the incision inline with Henry’s approach to the forearm to allow greater access in light of the delayed presentation incase there is any retraction and scarring requiring release. I would not anticipate significant retraction because the rupture is not complete.
What complications are seen with this procedure?
Nerve injury is most commonly seen. The lateral antebrachial cutaneous nerve is most frequently affected followed by the posterior interosseous nerve and the superficial radial nerve. The majority of these are transient neuropraxias. Also seen are problems resulting from errors in the cortical buft on deployment and heterotopic ossification. 38
Notes
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